FORM NO. 15H

FORM NO. 15H

[See section 197A(1C) and rule 29C(1A)]

Declaration under section 197A(1C) of the Income‐tax Act, 1961 to be made by an individual who is of the age of sixty years or more claiming certain receipts without deduction of tax.

PART - I

1] Name of Assessee (Declareant) :

2] PAN :

3] Age:

4] Assessment Year 2013-14

5] Flat / Door / Block No. :

6] Name of Premises :

7] Assessed in which Ward / Circle

8] Road / Street / Lane :

9] Area / Locality :

10] AO Code (under whom assessed last time) :

Area Code

AO Type

Range Code

AO No.

11] Town / City / District :

12] State :

14] Last Assessment Year in which assessed :

2012-13

13] PIN

15] Email :

16] Telephone / Mobile No :

17] Present Ward / Circle

18] Name of Business / Occupation :

19] Present AO Code (if not same as above):

20] Jurisdictional Chief Comm. of Income Tax or Comm. of Income Tax (if not assessed to income tax earlier):

Area Code

AO Type

Range Code

AO No.

21] Estimated total income from the sources mentioned below:

(Please tick the relevant box)

Dividend from shares referred to in Schedule - I

Interest on securities referred to in Schedule - II

Interest on sums referred to in Schedule - III

a

Income from units referred to in Schedule - IV

The amt of withdrawal referred in sec-80CCA(2)(a) from National Savings Scheme referred to in Schedule - V

22] Estimated total income of the previous year in income mentioned in Col - 22 to be included :

23] Details of investments in respect of which the declaration is being made :

SCHEDULE‐I

(Details of shares, which stand in the name of the declarant and beneficially owned by him)

No. of

Class of shares & face

Total value

Distinctive numbers

Date on which the shares were acquired

shares

value of each share

of shares

of the shares

by the declarant (dd/mm/yyyy)

SCHEDULE‐II

(Details of the securities held in the name of declarant and beneficially owned by him)

Description of

Number of

Amount of

Date(s) of

Date(s) on which the securitues were

securities

securities

securities

securities (dd/mm/yyyy)

acquired by declarant (dd/mm/yyyy)

SCHEDULE‐III

(Details of the sums given by the declarant on interest)

Name and address of the person to

Amount of sums

Date on which sums given

Period for which sums

Rate of

whom the sums are given on interest

given on interest

on Interest (dd/mm/yyyy)

were given on interest

interest

SCHEDULE‐ IV

(Details of the mutual fund units held in the name of declarant and beneficially owned by him)

Name and address of the

Number of

Class of units & face

Distinctive number

Income in

mutual fund

units

value of each unit

of units

respect of units

SCHEDULE‐V

(Details of the withdrawal made from National Savings Scheme)

Particulars of the Post Office where the account under the

Date on which the account

The amount of withdrawal

National Savings Scheme is maintained and the account number

was opened (dd/mm/yyyy)

from the account

x

Signature of the Declarant

Declaration / Verification

I .................................................... do hereby declare that I am resident in India within the meaning of section 6 of the Income –tax Act, 1961. I also, hereby declare that to the best of knowledge and belief what is stated above is correct, complete and truly stated and that the incomes referred to in this form are not includible in the total income of any other person u/ss 60 to 64 of the Income Tax Act, 1961. I further, declare that tax on my estimated total income, including *income / incomes referred to in column 21 above, computed in accordance with provisions of the Income Tax Act 1961, for the previous year ending on 31.03.20... relevant to the assessment year 2013-14 will be nil.

Place :

x

Date  :

Signature of the Declarant

PART - II

[For use by the person to whom the declaration is furnished]

1] Name of the person responsible for paying the income referred to in Column 21 of Part I :

2] PAN of the person indicated in Column 1 of Part II

3] Complete Address :

4] TAN of the person indicated in

Column 1 of Part II :

5] Email :

6] Telephone / Mobile No :

7] Status :

8] Date on which Declaration is Furnished (dd/mm/yyyy) :

9] Period in respect of which the dividend has been declared or the income has been paid / credited :

10] Amount of income paid :

11] Date on which the income has been paid / credited (dd/mm/yyyy) :

12] Date of declaration, distribution or payment of dividend/withdrawal under the National Savings Scheme(dd/mm/yyyy) :

13] Account Number of National Saving Scheme from which withdrawal has been made :

Forwarded to the Chief Commissioner or Commissioner of Income‐tax  ____________

Place :

Signature of the person responsible for paying the

Date  :

income referred to in Column 21 of Part I

Thank You